Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study. Bryant MK, Tatebe LC, Rajaram S, Udekwu PO, Wurzelmann M, Crandall ML, Zuniga YD, Tran V, Santos A, Krause C, et al. J Trauma Acute Care Surg. 2022 Jul 1;93(1): 75-83.
Incarcerated persons are considered a “vulnerable population” and have thus been protected, or as the authors point out, excluded from many research protocols since the 1976 Belmont Report outlined this protection to help prevent exploitation. However, the secondary effect of not studying the justice-involved patient population has led to a missed opportunity to understand the unique surgical needs and injury prevention strategies required to best serve this group. The authors explore this issue in a 12-month, prospective, twelve-center study which included a total of 943 trauma and emergency general surgery (EGS) patients incarcerated in jail, prison, or detention centers. They collected data on demographics and outcomes including complications, outpatient 90-day follow up, readmission or representation within 90-days, among others. Baseline characteristics revealed the EGS patients to be older (median, 41y vs. 31y, p<0.001), have fewer psychiatric diagnoses (20.5% vs. 38.6%, p<0.001), and be more likely to need an operative intervention (27.5% vs. 13.4%, p<0.001) than the trauma cohort. The most common trauma diagnoses were head injury (30.6%), soft tissue injury (27.1%), and facial fractures (13.5%). For EGS patients, the top admission diagnoses were soft tissue infection (13%), wound infection (10.7%), and biliary disease (5.6%). Overall complication rates were 12.8% for EGS patients and 3.7% for trauma patients (p<0.001). Overall follow up rate in the same institution was 28.6% and this was higher in the EGS group (32.9% vs. 25.1%, p=0.011), and the authors note this rate is lower than best-estimate national averages for hospital follow up in trauma patients which is closer to 60%.
The authors note their limitations including that the majority of patients came from a single, county hospital and that some patients may have been in and out of the justice system and may have actually followed up elsewhere. However, their conclusions remain important and prompt further research. They found that interpersonal violence was the most common cause of injury, which should inform trauma prevention; and that with 22% of EGS patients re-presenting to the ED within 90-days, questions are raised about post-operative complications and how they are managed in correctional facilities, as well as how information is shared between surgeons and the infirmary providers. It is also of note that non-white patients were half as likely to be readmitted than White patients, inviting us to study potential health care disparities. Finally, the authors conclude that an improved understanding of epidemiology and outcomes in this vulnerable population will bolster our ability to provide more patient-centered care and improve collaboration with correctional facility providers.
Mortality and pulmonary complications in emergency general surgery patients with COVID-19: A large international multicenter study. COVIDSurg Collaborative. J Trauma Acute Surg. 2022 Jul 1;93(1):59-65.
Since December of 2019 we have been grappling with complex decision making for COVID-19 patients, including the cancelation or delay of more than 28 million surgical cases in the early phase of the pandemic. The authors of this large, international, multicenter study looked at 1045 patients with a pre-operative diagnosis of SARS-CoV-2 and examined 30-day mortality and 30-day pulmonary complications. They included patients who underwent typical EGS operations: appendectomy, cholecystectomy, and exploratory laparotomy. Overall, non-survivors were more likely to be older than 50 years, had an ASA of 3 or more, and a BMI of 30kg/m2, had at least one respiratory comorbidity, and more often had a laparotomy. On multivariate analysis, the main independent predictors of 30-day mortality were age 50-69 years and ³ 70 years (OR [95% CI], 5.3 [1.14-24.63]) and (OR [95% CI], 5.67 [1.17-27.48]), respectively; undergoing a laparotomy (OR [95% CI], 5.74 [2.52-13.08]); and ASA Grade 4 or 5 (OR [95% CI], 6.95 [1.4-34.45]) and (OR [95% CI], 18.08 [3.22-101.49]), respectively. The main independent predictors of pulmonary complications were pre-operative respiratory findings of COVID-19 (OR [95% CI], 6.03 [3.44-10.6]), ASA Grade 4 (OR [95% CI], 4.67 [1.87-11.66]), and undergoing a laparotomy (OR [95% CI], 3.24 [1.97-5.32]). Patients with pre-operative respiratory findings of COVID-19 had a significantly higher mortality than those without (22.6% v. 3.0%. p<0.001). This is in comparison to non-COVID-19 patients with an estimated mortality of 14.9% from prior studies.
The authors concluded that both mortality and pulmonary complication rates for patients with COVID-19 undergoing EGS procedures are significantly elevated, especially in patients with pre-operative respiratory findings. This trend held true even for the traditionally lower risk operations of appendectomy and cholecystectomy. The authors suggest that in selected patients with COVID-19, weighing the risk/benefit of early operation vs. delayed operation, such as in the case of considering antibiotics alone for uncomplicated appendicitis, may be warranted. The authors note the limitation of extrapolating these results to current COVID-19 cohorts in the era of vaccinations, as this study was completed before vaccines were available. They report ongoing data collection to inform our new vaccine era. In summary, the authors present a straightforward paper that illuminates the mortality and pulmonary risks associated with COVID-19 for our most common EGS procedures.
Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial. Boden I, Sullivan K, Hackett C, Winzer B, Hwang R, Story D, Denehy L. J Trauma Acute Care Surg. 2022 Jun 1;92(6):1020-1030.
The high rate of postoperative complications following emergency abdominal operations is well recognized and represents a significant burden for these patients and the health care system. Meanwhile, benefits of early physical therapy and mobilization after surgery are well recognized. This is the single-center pilot phase of a randomized, controlled, prospective trial which seeks to understand whether postoperative complications such as pneumonia may be impacted by implementation of more intensive physical therapy intervention sooner after emergency abdominal surgery. The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial is assessing the feasibility and safety of implementing more intensive early physical therapy after emergency abdominal surgery involving an incision greater than or equal to 5cm above, or extending above the umbilicus. Fifty adult (18 years or older) patients who required emergency abdominal surgery were randomized to either standard care or intensive physical therapy. Intensive physical therapy consisted of twice daily coached breathing exercises for two days and 30 minutes of daily supervised rehab over the first five postoperative days.
There were several barriers limiting adherence to treatment plans including therapist availability and patient fatigue, limiting intervention provided exactly as per protocol to only 35% of patients. Despite barriers to treatment, patients randomized to intensive therapy received twice as many breathing exercise sessions and four times the amount of physical therapy over the first five postoperative days. Only one adverse event was noted and resolved without escalation of medical care. The authors conclude that intensive physical therapy can be delivered safely and effectively over the first five postoperative days after emergency laparotomy. The results of this pilot study recommend moving forward to the multicenter phase of the ICEAGE trial. We look forward to seeing the potential impact of early intensive physical therapy on this vulnerable patient population.
Development and implementation of an automated electronic health record-linked registry for emergency general surgery. Mou Z, Sitapati AM, Ramachandran M, Doucet JJ, Liepert AE. J Trauma Acute Care Surg. 2022 Aug 1;93(2):273-279.
Health care quality initiatives have evolved significantly as our ability to capture and analyze large data registries has evolved. Such a registry for emergency general surgery (EGS) patients has lagged behind, likely due at least in part to the tedious and labor-intensive efforts required to construct such a registry. However, this particularly vulnerable population would be well-served by the potential benefits of such a registry. In this single center report, the authors describe utilization of the electronic health record (EHR) to automate data collection for an internal registry at one institution. This automation has a substantial impact on the resources required to construct such a registry, making the potential use and benefit more accessible to more surgeons.
Existing EHR labels were used to create inclusion automated inclusion rules for data capture. Registry validation was performed using a 30-month retrospective cohort and 1-month prospective cohort. The retrospective data set had a false-positive detection rate of EGS patients of 1.8%, and the prospective set had a false-positive rate of 0%. Internal quality metrics were reported to the team via the registry streamlining adherence to quality measures and allowing for identification of quality improvement initiatives. There is clear potential to integrate multiple institutions with the same EHR to expand such a registry and compound the potential impact on outcomes data.